The Priority Series

Whether you need to be hospitalized for a planned hospital procedure or need emergency cover, the Priority Series offers cover in a private hospital with no overall limit.

We cover you in any private hospital for emergency and planned hospital admissions that you have authorised with us.

Emergency cover when you need it most

In an emergency, go straight to hospital but call us or get someone to call us within 12 hours.

If you need medically-equipped transport in a medical emergency, call 0860 999 911. This line is managed by highly qualified emergency personnel who will send the most appropriate air or road emergency evacuation transport.

Cover for planned hospital admissions

Please call us at least 48 hours before you go to hospital to confirm your admission.

No overall limit

There is no overall hospital limit on the Priority Series. Limits, clinical guidelines and policies apply to some healthcare services and procedures.

Deductibles for in-hospital procedures

You need to pay an amount upfront (a deductible) to the hospital when you are admitted for one of the following procedures:

If the procedure can be done out of hospital, for example in the doctor’s rooms, and you don’t go to hospital, you won’t have to pay a deductible. Please call us beforehand to confirm your benefits.

We have negotiated with the majority of specialists to guarantee that when you use a specialist in our payment arrangements we pay them directly at our agreed rate. This means that when consulting a specialist in our payment arrangements you will be covered in full.

Full cover for specialists participating in our payment arrangements

You can benefit by using healthcare professionals participating in our direct payment arrangements because we will cover their approved procedures in full. If you are a Classic Priority Plan member, you benefit from access to the broadest range of specialists whom we pay in full, which represents over 87% of specialist interactions.

You may have a co-payment if you use other specialists

If you are treated in hospital by a specialist who does not participate in one of our payment arrangements, we cover you up to 200% of the Discovery Health Rate on the Classic Priority Plan and up to 100% of the Discovery Health Rate on the Essential Priority Plan.

Other healthcare professionals

We cover GPs, and other healthcare services up to 200% of the Discovery Health Rate on Classic Priority and up to 100% of the Discovery Health Rate on Essential Priority.

We cover radiology and pathology up to 100% of the Discovery Health Rate on all plans.

MRI and CT scans

If you are in hospital as part of an approved hospital admission, we cover your MRI or CT scan up to the Discovery Health Rate from your Hospital Benefit.

If you are admitted for conservative back or neck treatment, you will need to pay the first R1 600 of the hospital account, and the first R2 100 of the scan code is paid from your day-to-day benefits. We pay the balance from your Hospital Benefit up to the Discovery Health Rate. You are limited to one MRI or CT scan a year for conservative back and neck treatment.

You need to pay a portion (deductible) of your hospital or day clinic account upfront for dental admissions. This amount varies depending on the member’s age and the place of treatment.

We pay the balance of the hospital account from the Hospital Benefit, up to 100% of the Discovery Health Rate.

We pay the related accounts, which include the dental surgeon and anaesthetist’s accounts, from the Hospital Benefit up to 100% of the Discovery Health Rate.

No overall dental limit

There is no overall limit for dental treatment. However, all dental appliances and orthodontic treatments (including the related accounts for orthognathic surgery) are paid up to 100% of the Discovery Health Rate from your day-to-day benefits, up to an annual sub-limit of R10 000 a person. We pro-rate this benefit according to when you join the medical scheme. The overall Above Threshold Benefit limit applies.

Severe dental and oral surgery

The Severe Dental and Oral Surgery Benefit covers a defined list of procedures with no deductible and no overall limits. This benefit is subject to authorisation and the Scheme’s clinical entry criteria.

Most of your in-hospital healthcare services have no overall limit. These include:

• GPs
• Specialists
• Allied healthcare professionals, for example physiotherapists
• Pathology and radiology
• HIV cover if you are registered on the HIVCare Programme

Only the following healthcare services have a limit:

Your cover for chronic conditions

The Chronic Illness Benefit offers you flexible cover for chronic conditions – you always have the option of full cover through our medicine list (formulary) or the choice of using any medicine up to a set monthly amount.

You have flexible cover for a list of chronic conditions. You have full cover for approved medicine on Discovery Health’s medicine list (formulary) or up to a set amount for medicine not on our list.

We pay medicine up to a maximum of the Discovery Health Medication Rate. We need to approve your chronic condition before it is covered from the Chronic Illness Benefit.

Your cover for cancer treatment

DiscoveryCare’s Oncology Programme covers you for cancer treatment.

DiscoveryCare’s Oncology Programme covers the first R200 000 of your approved cancer treatment over a 12-month cycle, in full. Cover is unlimited once your cancer treatment costs go over this amount but you need to pay 20% of the costs of all further treatment from your pocket.

Radiology and pathology approved for your cancer treatment is also covered. Cancer treatment that falls within the Prescribed Minimum Benefits is always covered in full, with no co-payment. Please call us to register on the Oncology Programme.

We cover chemotherapy and any oncology-related medicines up to the Discovery Health Medication Rate. Consultations, radiotherapy, radiology, pathology and scans are paid up to the Discovery Health Rate. You may be responsible for a co-payment if your healthcare provider charges more than the applicable Discovery Health Rate.

The Medical Savings Account puts you in control of your day-to-day medical expenses. Any unused money is carried over to the following year.

We pay for your day-to-day medical expenses like GP visits, x-rays and blood tests from your Medical Savings Account, as long as you have money available. You may need to pay for your day-to-day medical expenses if you have run out of money in your Medical Savings Account before your claims add up to the Annual Threshold.

Once your claims add up to the Annual Threshold, we pay the rest of your claims from the Above Threshold Benefit at the Discovery Health Rate. Your Above Threshold Benefit has an overall limit. Once this limit is reached we will not cover any more day-to-day medical expenses.

Extending your day-to-day cover

Early detection and prevention of diseases is vital to your wellbeing. The Screening and Prevention Benefit pays for a range of healthcare services that help to prevent and screen for diseases that would otherwise go unnoticed.

Discovery Health pays claims for some day-to-day expenses to make the money in your Medical Savings Account
last longer:

• The Screening and Prevention Benefit covers a range of healthcare services, including the following tests at a Discovery Wellness Network provider: blood glucose, blood pressure, cholesterol and body mass index. The benefit also covers a mammogram, Pap smear, PSA and HIV screening tests. Members from the age of 65 and members registered for certain chronic conditions are also covered for a seasonal flu vaccine from this benefit.
• We will cover out-of-hospital claims for your recovery after certain traumatic events from the Trauma Recovery Extender Benefit. The cover applies for the rest of the year in which the trauma takes place, as well as the year after your trauma.
• For endoscopies (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy) that are done out of hospital, the deductible does not apply. We pay up to 200% of the Discovery Health Rate if you are on a Classic Priority Plan. We pay up to 100% of the Discovery Health Rate if you are on an Essential Priority Plan. Please call us before you have a scope in your doctor’s rooms to confirm your benefits.

 The Insured Network Benefit ensures you have no gaps in cover for GPs and pathology in our network

The Insured Network Benefit covers GP consultation fees, and blood tests requested using the Discovery Health pathology form, at our network providers, to ensure that you don’t have any gaps in cover.

We further extend your day-to-day cover through the Insured Network Benefit. When you have spent your annual Medical Savings Account deposit:

• We cover the full cost of your consultation fees if you go to a GP in our network. We pay the claim directly to the GP.
• We cover blood tests at our network providers if your GP or specialist requests the appropriate tests using the Discovery Health pathology form.

The Above Threshold Benefit offers extra day-to-day cover

Your day-to-day cover is further extended through the Above Threshold Benefit – a safety net that covers you when your expenses addup to a set amount.

The Priority Series includes an Above Threshold Benefit that gives you further day-to-day cover when your Medical Savings Account runs out and when your day-to-day claims add up to a set rand amount. On the Priority Series, the Above Threshold Benefit has an overall limit.

For you to get to your Above Threshold Benefit, we add your claims up to your Annual Threshold. Here are the amounts that we add up:

• For Premier Rate specialists, we add up the Premier Rate. For non-participating specialists, we add up the Discovery Health Rate.
• For generic medicine, we add up 100% of the Discovery Health Medication Rate. For non-generic medicines, we add up 75% of the Discovery Health Medication Rate. Over-the-counter medicines do not add up to your Annual Threshold.
• We add up the Discovery Health Rate for all other healthcare services.

We add up the amount to the benefit limit available.

No annual limit on some day-to-day healthcare services

We pay for these healthcare services from your Medical Savings Account with no annual limit:

• GPs
• Specialists
• Allied healthcare professionals, for example physiotherapists
• Pathology and radiology
• We will pay the first R2 100 of your MRI or CT scan code from your day-to-day benefits. We cover the balance from your Hospital Benefit up to the Discovery Health Rate

Limits on some day-to-day healthcare services

Some of your day-to-day benefits have limits. These limits apply to claims paid from your Medical Savings Account and Above Threshold Benefit.

* We pro-rate this benefit according to when you join the medical scheme.

Annual Threshold amounts

Discovery Health does not cover certain healthcare services. You can find a full list of these exclusions here.

We market our Discovery Health Plans through independent and accredited financial advisers. If you want a financial adviser to help you choose a Health Plan to suit the needs of your family, please send us your contact details and we will contact you.